Are Florida doctors prepared to treat patients with medical marijuana?

A marijuana plant awaits judging in the Oregon Cannabis Growers' Fair last year. In Florida, more than 39,000 residents have signed up through the state health department to receive medical marijuana as a form of treatment for a list of qualifying illnesses since the registry opened in 2016. But some say their state-approved physicians seem tentative in their knowledge about the substance. [Associated Press]

Richard Hackler recently drove five-plus hours round trip from his home in Vero Beach to St. Petersburg, hoping to find out if medical marijuana could help with his post traumatic stress disorder.

But the doctor he traveled to see seemed just as uninformed as the other physicians he had visited in Melbourne and Stuart. Though all three had been qualified by the state to prescribe medical marijuana, none of them, he said, seemed to know much about the plant or its ability to treat cases like his.

"These doctors are not educated enough," said Hackler, a 60-year-old veteran who was particularly miffed about the low doses the doctors wanted to offer him. "They don't know a thing about dosages or what they are prescribing."

He's not alone.

Donna Doucette, a retired registered nurse who lives in Pinellas Park, is still in pain after trying five combinations of cannabis levels recommended to her by a state-qualified doctor in Tampa.

"Nothing helps my nausea or decreases my need for opiate pain control," she said. "I feel I need a more experienced physician to help me maneuver this totally unknown alternative to mainstream medicine. … At this point we are out there on our own and there is no connection between the physicians and the providers of the cannabis."

Patients, she said, are left "adrift."

More than 39,000 Floridians have signed up through the Florida Department of Health to receive medical marijuana as a form of treatment for a list of qualifying illnesses since the registry opened in 2016. And more than 1,000 physicians have taken the state-mandated course that officially qualifies them to examine those patients and recommend products that might help.

But some patients are finding themselves in the unsettling position of being in the examining room with physicians who seem tentative, unable to speak with much authority about medical marijuana.

One issue may be the state course, which doesn't go into great detail about dosages, common side effects and other information doctors should have when recommending the substance to patients — at least not to the degree the U.S. Food and Drug Administration does with legal prescription drugs.

And the course, initially eight hours long at a cost to doctors of $1,000, now lasts only two hours under a new Florida law. The cost has been slashed to $250.

Even before it was shortened, the state course "was pretty basic and focused mostly on the legal ramifications," says Dr. Genester Wilson-King, who operates Victory Rejuvenation Center in Lake Mary near Orlando.

She offers another explanation for what patients are seeing with their doctors: Medical schools didn't teach their students about cannabis until recently, which isn't helpful to the many physicians who are trying to get up to speed on recommending cannabis now.

"There was no medical school curriculum about this during my time, and there are maybe a handful of medical schools that are now teaching it," said Wilson-King, a board-certified OB/GYN physician whose business has focused mostly on general health and wellness in recent years. She's also on the board of the Society for Cannabis Clinicians, a national nonprofit with 300-plus members dedicated to educating physicians about the medical use of cannabis.

"With any new procedure, there's a learning curve," Wilson-King said. "Physicians are quite smart and fast learners. And the beauty of cannabis is that its side effects are short-lived. You can overdose on cannabis, but you won't die from an overdose. Most doctors start low and go slow with patients, and that way, they're not going to do any harm."

• • •

Hackler is no novice when it comes to medical marijuana. He had previously qualified to use it in California, and he'd done his research. But after spending countless hours getting appointments and paying hundreds of dollars at doctor's offices in Florida, he was ready to give up.

"What the doctor wanted to give me was useless. It would have been a waste of time," he said. "It's totally contrary to why I need marijuana to begin with."

Hackler said he felt like the doctor in St. Petersburg was trying to "dig deep" to re-trigger his PTSD by asking so much about it. But it was the low dosage he offered that bothered him the most.

"I asked him why I should pay hundreds of dollars for something I knew wouldn't help me, so then he tried to change the dose around, which was not OK."

Eventually, Hackler came to a compromise with the physician, and now has a recommendation he thinks will help him. The doctor also is helping him sign up through the state's registry so he can start using cannabis.

"We overcame my concerns. The doctor was possibly being overly cautious, whereas I already knew what I needed," Hackler said. "He eventually relented."

But the interaction was frustrating, particularly after Hackler struck out when he tried to be evaluated by two other state-qualified physicians. One provider started registering Hackler with the health department without ever speaking to him, he said. "Another doctor wanted to see me for appointments over Skype."

• • •

Dr. Doug Scott said he's been learning about medical marijuana as he goes. That's what he told a Tampa Bay Times reporter and Doucette, the patient from Pinellas Park.

"He assured me with my multiple chronic diseases and pain from multiple orthopedic and spinal surgeries that he would approve me for the program," Doucette said, describing her March 20 appointment with Scott. "He also told me he had just taken the exam and was just learning about cannabis."

Scott is a physician with Tetra Health Centers, a California-based chain of walk-in clinics that specialize in cannabis recommendations. He works at the company's South Tampa office, and says the majority of the patients he sees are seniors.

But no matter the age of the patient, there are "a lot of gray areas" where doctors can make the decision on whether to prescribe marijuana on a case-by-case basis, Scott said, especially for chronic pain diagnoses.

"A lot of people come in and want to take cannabis to get off pain management medication, but it's dangerous if they take cannabis with pain meds," he said.

After finding no cannabis balance to ease her pain, Doucette wonders if it's even worth trying to meet with another doctor who could help her.

"I have had bad dreams and dizziness as side effects," she said. "There needs to be some type of support group, online or in person, for users to exchange ideas on what worked for me, what I tried that did not work and what really helped me."

Even at a local dispensary, where she went with her doctor recommendation, Doucette said she felt that the employees were "all young, inexperienced workers who were very nice and compassionate, but lacked the experience and maturity to really be of assistance."

Hackler said this kind of system, which felt eerily familiar to "pill mill clinics" is what bothered him. Several features give it a different feel from regular health care.

At Tetra, which has a half-dozen clinics in Florida, patients can walk in or make an appointment to see a doctor, get registered with the state, and walk out with a recommendation.

And it's not like getting your medications from a pharmacy.

With prescription drugs, physicians can monitor which drugs patients are using through the state's database. But medical marijuana isn't listed there because it's still a federally illegal substance and, technically, physicians can't "prescribe" it to patients.

Because marijuana is still illegal at the federal level, the way it's regulated varies from state to state. There are often gaps in terms of restrictions and education, experts say. And laws surrounding medical marijuana use in Florida change nearly annually with each new legislative session, forcing physicians and dispensing companies to alter their practices as guidelines change.

• • •

The Florida Medical Association and Florida Osteopathic Medical Association oversee the required course for Florida physicians interested in recommending cannabis. Doctors, many of whom took the original eight-hour course, are expected to retake the newer two-hour program and exam when they renew their medical license each year.

Wilson-King says the shorter, cheaper test is good news, in that it reduces the barrier of entry for doctors who want to be able to recommend cannabis. But it's up to each physician to seek out additional education about using it as a medicinal treatment.

That could be a problem, said Savara Hastings, executive director of the Florida-based American Medical Marijuana Physicians Association, who argues that the state health department needs to finish writing formal rules to go with Florida's new law on medical marijuana.

"Until that happens, physicians are concerned that this compliance ambiguity will lead to increased risk and liability," she said. "Medical marijuana may have incredible value in the treatment of certain medical conditions, however, we need to proceed cautiously as more studies need to be completed."

Hastings says doctors often rely on industry association conferences and courses once they're registered with the state. Her association, which has 650 active members in Florida, is hosting a conference in Orlando this month.

"Most medical marijuana conferences offer seminars on how to grow your own marijuana, how to get rich quick, how to make marijuana-infused pudding, and how marijuana will both cure cancer and convince Kim Jong Un to turn over the key to his nuclear weapons at the same time," Hastings said.

It's difficult to cut through that kind of clutter to reach physicians who are serious about the topic, she said.

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